Knowing when and where to implement various techniques is one of many important aspects of tactical medicine. In a previous entry, we discussed weapons placement during treatment. We proposed positioning your primary weapon behind your knees when the tactical situation allows. The video below is a prime example of when this technique should not be used. The medic is supposed to be in the Care Under Fire (CUF) phase. In this phase of tactical medicine, while treating in the prone position, your weapon should be immediately accessible and ready to engage threats. Due to positioning, you do not have rapid access to your secondary weapon. Slinging your weapon is not a sound choice, because its position will hinder putting it into operation. Your best choice in this situation may be to un-sling your weapon and route your arm through the sling. Don’t, however, put the sling all the way on. Next, set the weapon on your casualty, making an effort not to burn them with a hot barrel. Routing your arm through the sling maintains a point of attachment and acts as a friendly reminder; however, it doesn’t interfere with your ability to provide treatment. When you move, your weapon will still move with you and is readily accessible for periodic engagements.

Most courses teach not to use your casualty as a work table or place supplies and equipment on them. This is a good habit to get into, but this is a definite exception. Your weapon is now a lifeline for you and your casualty, and it needs to be readily accessible.

TacMed Key Points:

1) Situation dictates weapons placement
2)CUF phase requires your weapon to be accessible no matter your position
3)In order to increase your and your casualty’s chance of survival, you may have to “break a rule” and use him as a table or a firing platform.

Providing care under fire is a mentally daunting task. Few other phases have so little to do with medicine and so much to do with your surroundings. Even with a sizable piece of cover, it is easy to make mistakes and expose yourself during treatment when focused on patient care.

In the video you can see the medic doing a decent job of maintaining a low profile during treatment, then, while shifting from the casualty’s leg to his head, he elevates his body during movement. This action briefly exposes his head to enemy fire. An analogy we like to use to explain the atmosphere you are operating in when providing true “care under fire” is that it can be equated to working in confined space. The difference is that instead of bumping your head or elbow on a concrete slab, the concrete slab is replaced by incoming fire. It is generally best for everyone if the medic avoids bumping parts of his body into bullets.

The effort to maintain your position of cover is exponentially more difficult in urban areas or areas with varying points of elevation. You should regularly reassess the effectiveness of you position as the fight progresses. If the enemy force has moved to an elevated position, or possibly to the second or third story of a surrounding structure, you just lost about 50% of your position. Now you must either be more cautious when moving to provide treatment or you need to shift to maximize the use of the position you are in. If in a structure with external windows and “plunging fire” from surrounding buildings, the safest position is on an external wall, in the corners, away from windows. However, remember to consider the type of materials used to construct the building before selecting this position. This position is not recommended if in a vinyl-sided home or a 3rd world type structure.

Failure to practice working in tight quarters behind cover can lead to potentially fatal mistakes in combat. Incorporate these situations into your training and use them to increase the effectiveness of your equipment (e.g., how and where you store or pack it) and how to asses your positions.

Here are some tips for operating in this phase of tactical medicine:
-Keep items required for Care Under Fire or buddy-aid easily accessible.
-Reposition casualties to minimize their level of exposure and yours.
-Don’t lose touch with your surroundings, regularly reassess the enemy’s position.
-Don’t be afraid to move to a new position if the tactical situation allows.
-If in a structure, be mindful of interior and exterior threats.
-Keep your treatments as simple as possible then get back on your gun!

A medic’s bag is never big enough, but it’s always too big. There is no way for you to carry enough medical equipment in your bag to treat every possible injury. If you over pack your bag, it makes it difficult to work out of, it slows you down and it limits your ability to maneuver through the battlespace. If you under pack, you might not have the items you need to treat a serious casualty.

One way to maximize the medical supplies on the objective while minimizing the burden on the medic is to cross-load supplies. Medics carry ammunition for their weapon; operators should carry supplies for their wounds. This has been practiced for quite some time in the military, but it is just making its way into the civilian/ Law Enforcement sector. Soldiers are issued individual first-aid kits containing the essential items for initial care on the battlefield. The majority of what is needed for self-aid and/or buddy-aid is contained in these kits, and they are a great example of cross-loading on a massive scale.

When considering items for cross-loading, look at items individuals are actually trained to use and that take-up a lot of space in your bag. Bandages and tourniquets are good examples of items that are high-volume items in both use and consumption of space. Spreading these items throughout your element will be a major help in a few ways. For example:

1. It reduces the medic’s load
2. It spreads medical assets across the team reducing treatment times.
3. Increases the amount of medical supplies on the objective

Items recommended for cross-loading:

1. Bandages
2. Tourniquets
3. Chest-seals
4. Snivel meds (OTC Drugs)
5. IV fluids

Specialty items that are medic-specific tools should not be cross-loaded. These are items you want to protect and have at your immediate disposal if required. Some of those items include:

1. Advanced airway management
2. Special diagnostics
3. Pain-control meds (this is unit dependent)
4. Surgical instruments

What you decide to cross-load should be based on mission requirements, level of your teams’ medical training, medical director’s guidance, and local protocols. Every organization will have different requirements based on the above factors. It’s up to you to develop your plan.